The provider gift ban: The day the tchotchkes died

It wasn't until 2009 that PhRMA called for a voluntary ban on the industry's promotional trinkets. Photos courtesy of Sara Bellakbira, PharmedOut.

For years, pharma helped keep the manufacturers of Lipitor pens, Prevacid golf club head covers, and other promotional items in business. But when the Pharmaceutical Research and Manufacturers of America imposed a voluntary ban in 2009 that relegated these and similar tchotchkes to the promotional netherworld of eBay auctions and displays in physicians' offices, nobody expected them to have much of a collectible afterlife.

The decision to enact the ban was a no-brainer. PhRMA was not alone in sensing a need to clean up the industry's image by addressing the ethics of providing an array of branded gifts to physicians. Gimmicky marketing mementos like Post-it notes and pens may have seemed harmless enough, but the prescribing influence they carried came into question.

“These items were constantly in view and intended to keep specific drug names uppermost in physicians' subconscious. And it worked,” says Dr. Adriane Fugh-Berman, an associate professor in the departments of pharmacology and physiology and family medicine at the Georgetown University Medical Center. Fugh-Berman is also director of PharmedOut, a Georgetown research and education project that, per its website, “promotes rational prescribing and exposes the effect of pharmaceutical marketing on prescribing practices.”

These relics of the past have a certain value for those on the hunt. One eBay seller hopes to fetch $20 for a blue pill-shaped Viagra promotional clock that doubles as a business card holder, an item that was once a big weapon in the Pfizer sales rep's arsenal of freebies. And those golf club head covers — in the shape of a stomach, designed to somewhat subtly remind docs of Prevacid's utility in treating heartburn — still make occasional appearances on golf courses across the U.S. In fact, AbelsonTaylor president and CEO Dale Taylor recently spotted a set on a Chicago fairway — in mint condition, no less.

LOW-BROW HIGH JINKS?

According to several pundits, the PhRMA ban served to eradicate a source of obvious commercial bias just sitting there on doctors' desks.

“Many physicians thought the ban was silly, but that's because they were — and are — unaware of the effect of small gifts on creating a sense of obligation,” Fugh-Berman says. “There was also a certain amount of consternation among some docs, who couldn't figure out how to procure a pen that had not been provided by a pharmaceutical company.”

According to Dr. David Lee Scher, a cardiologist and digital health technology consultant at DLS Healthcare Consulting, some physicians were upset when the tchotchke well dried up, but not for the aforementioned reasons. “It wasn't the inability to obtain the gifts. Rather, it was the loss of a line of communication to the company about product education,” he explains. “Pharma must have thought the tchotchkes translated into prescriptions, but personally, those things never influenced me.”

THE PHYSICIAN–SALES REP LINE

Scher, however, contends that the ban had a broader effect than intended, unintentionally creating physical and regulatory barriers to pharma–provider communication. When the promotional items became obsolete, so too did many of the field representative calls. “I no longer had a person to call when I needed information about new and existing drugs,” he shrugs.

Taylor doesn't buy that line of thinking. “Though they may not cop to it, physicians were disappointed about the gifts on some level,” he says. “Some docs would complain when the sticky notes weren't sticky enough or when a pen design changed. They were using the items.”

On the pharma side, the ruling may actually have been a blessing. Ditching the tchotchkes was a relatively easy way for the industry to respond to public scrutiny, plus pharma manufacturers stood to save large amounts of money by halting production of the items.

Not everyone was quite so thrilled. “For us — the agencies — we were disappointed,” Taylor admits. “Tchotchkes were a clever way to expand branding and generate revenue.” Some of the items, he adds, were designed to reach prescribers with important messages. Taylor recalls a cement mixer emblazoned with a logo for Janssen's Elmiron, a drug intended to repair the bladder's mucosal lining in patients with interstitial cystitis. The giveaway was designed to elevate physicians' understanding of the product by comparing its mechanism to a cement mixer's resurfacing capability.

Still, Taylor agrees that no one truly believed that the tchotchkes changed prescribing behavior. “The items were a toll that companies paid to gain access to physicians,” he says bluntly.

Fortunately for those in the agency world, the PhRMA ban coincided with a shift to a more sophisticated advertising and marketing approach. “Those items may have gone away, but we saw the rise of another suite of communication practices,” Taylor continues. “Suddenly, we were using the internet and digital channels to carve out more compelling sales stories and involve the audience in ways we never did before.”

NEXT TARGET: CME?

With the eradication of industry gifts to physicians, gone too is the concern of subtly influencing professional judgment in the care of patients. Or is it? Criticism of CME and DTC promotion has been gaining traction.

Some wonder why the tchotchkes are still a topic of conversation in 2016. “While pens, pads, and the like were common in the industry, their absence has not been a big milestone in the modern history of medical marketing,” shrugs John Kamp, executive director of the Coalition for Healthcare Communication.

Much more important in Kamp's mind was the FDA decision in 1997 to enable widespread broadcast DTC advertising — and the subsequent failures by then Rep. Henry Waxman and Sen. Edward Kennedy to effectively ban it via legislation. “The controversy over DTC advertising may not be over,” Kamp says. “Hillary Clinton has put it on her list of priorities if she's elected.”

WHAT SACRIFICE?

Those in the dissenter camp look at the gift moratorium as little more than a Band-Aid atop a gushing wound. To hear Fugh-Berman tell it, pharmaceutical companies jettisoned promotional items without much thought — and at least in part to preserve their influence in other, less obvious venues, such as CME.

“It was a sacrifice, but it was a sacrifice of the least-favorite child,” Fugh-Berman points out. In turn, pharma marketers focused on more covert forms of promotion, like disease-awareness campaigns and DTC promotion.

Along those lines, the voluntary PhRMA moratorium, the Accreditation Council for Continuing Medical Education's commercial support standards, and the FDA guidance on industry-supported education all emphasize the need to separate promotion from education. “Each regulation reinforced the importance of independent education and creating a safe space for learning,” notes Dr. Graham McMahon, ACCME's president and CEO. “It was, and is, in the best interest of all concerned.”

McMahon insists that accredited CME will continue to evolve and meet the changing needs of its learners, embracing best practices and engaging physicians in high-quality development activities into the foreseeable future. “Our learners' educational needs will drive their skills, not promotional or marketing materials that may have had influence in the past,” McMahon says.